above
hyper
below
hypo
joint
arthro
bone
osteo
bile
chole
inflammation
itis
pain
algia
high blood pressure
hypertension
hypertension
HTN
high cholesterol
Hyperlipidemia
hyperlipidemia
HLD
diabetes
diabetes mellitus
diabetes mellitus
DM
I only take pills for my diabetes
Non-Insulin Dependent Diabetes Mellitus
non-insulin-dependent diabetes mellitus (type 2)
NIDDM
I take shots(insulin) for my diabetes
Insulin Dependent Diabetes Mellitus
insulin dependent diabetes mellitus (type 1 or type 2)
IDDM
cancer
cancer or carcinoma
cancer or carcinoma
CA
heart disease
Coronary Artery Disease (CAD)
coronary artery disease
CAD
Heart Attack
myocardial infarction
myocardial infarction
MI
Heart Failure
Congestive Heart Failure (CHF)
congestive heart failure
CHF
abnormal rhythm
arrhythmia (can specify if mentioned)
asthma
asthma
Emphysema/Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
chronic obstructive pulmonary disease
COPD
blood clot in the lung
Pulmonary Embolism (PE)
pulmonary embolism
PE
pneumonia
Pneumonia (PNA)
pneumonia (acronym)
PNA
reflux
Gastroesophageal Reflux Disease (GERD)
pancreatitis
pancreatitis
Hepatitis
hepatitis
Diverticulitis
Diverticulitis
Crohn's/UC
Crohn's Disease or Ulcerative Colitis
Irritable bowl
Irritable Bowel Syndrome (IBS)
irritable bowel syndrome
IBS
bladder infection
Urinary Tract Infection (UTI)
kidney infection
Pyelonephritis (Pyelo)
kidney stone
renal calculi
Im on dialysis
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD)
chronic renal failure
CRF
end-stage renal disease
ESRD
enlarged prostate
Benign Prostate Hypertrophy (BPH)
benign prostatic hypertrophy
BPH
GPA
gravida, para, abortus
stroke
Cerebrovascular Accident (CVA)
cerebrovascular accident
CVA
brain bleed
Hemorrhagic Cerebrovascular Accident (CVA)
brain blockage or clot
Ischemic Cerebrovascular Accident (CVA)
mini-stroke
Transient Ischemic Attack (TIA)
transient ischemic attack
TIA
blood clot in my leg
Lower Extremity Deep Vein Thrombosis (DVT)
deep vein thrombosis
DVT
bulge in my aorta
Abdominal Aortic Aneurysm (AAA)
abdominal aortic aneurysm
AAA
Bad blood flow to my legs
Peripheral Vascular Disease (PVD)
peripheral vascular disease
PVD
numbness in my legs
peripheral neuropathy
low back pain
Chronic Low Back Pain
arthiritis
osteoarthritis (OA) or rheumatoid arthritis (RA)
osteoarthritis
OA
rheumatoid arthritis
RA
weak/ fragile bones
osteoporosis
removal
-ectomy
creating opening/hole
-ostomy
incision cutting into
-otomy
surgical repare
-rrhaphy or -plasty
tonsils removed
tonsillectomy
Adenoids removed
Adenoidectomy
ear tubes
Pressure Equalizer (P.E.) Tubes
PE tubes
pressure equalizing tubes
hearth cath
cardiac catheterization
balloon
Angioplasty --> PMHx CAD
stents
Coronary Stents --> PMHx CAD
heart bypass
Coronary Artery Bypass Graft (CABG) --> PMHx CAD
coronary artery bypass graft
CABG
breast removal
mastectomy
hole in my neck
tracheostomy
part of my lung removed
Partial lobectomy
appendix removed
appendectomy
gallbladder removed
cholecystectomy
hernia repair
Herniorrhaphy
part of my colon removed
Partial colectomy
bag to collect stool
colostomy
spleen removed
splenectomy
stomach stapled
Bariatric Surgery (gastric sleeve, gastric band/lap band, gastric bypass, etc.)
kidney removed
nephrectomy
uterus removed
hysterectomy (partial or total)
ovary removed
oophorectomy
Ovary and fallopian tubes removed
Salpingo-oophorectomy
tubes tied
Tubal ligation (female) or Vasectomy (male)
C-section
cesarean section
prostate removed
Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP)
transurethral resection of the prostate
TURP
uterine product removed
Dilation and Curettage (D&C)
dilation and curettage
D&C
neck artery cleaned
carotid endarterectomy
shunt
cerebral shunt
brain surgery
Craniotomy (brain bleed vs. brain CA)
Dialysis fistula
AV (arteriovenous) Fistula
Dialysis graft
AV (arteriovenous) Graft
atrioventricular
AV
Peripherally Inserted Central Catheter (PICC) (short term)
PICC line
port
Port-a-cath or Medi-Port (long-term)
Clot filter (lower abdomen)
IVC (inferior vena cava) filter
inferior vena cava
IVC
leg amputation
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
above knee amputation
AKA
below knee amputation
BKA
joint repair
arthroplasty
metal plates/pins
hardware
Symptoms related to the chief complaint.
associated symptoms
specific symptoms that are not present which cause the physician to doubt certain diagnoses
pertinent negatives
the simultaneous presence of two chronic diseases or conditions in a patient
Comorbidities
this medication indicated high cholesterol
-statin
strep throat
Strep Pharyngitis
ear infection
otitis media
Degenerative Disc Disease
DDD
bulging/herniated disc; causes back pain
Degenerative Disc Disease
painful urination
dysuria
blood in urine
hematuria
A pregnancy outside of the womb, usually in a fallopian tube
Ectopic Pregnancy
the act of twisting or the state of being twisted referring to organs
Torsions
Infection of skin cells
Cellulitis
local hard area on the skin
induration
localized collection of pus
Abscess
Opportunistic bacteria that causes persistent diarrhea
C. Diff Colitis
Vomiting and diarrhea; "GI Bug" often viral or bacterial
gastroenteritis
Immune disorder causing diarrhea and abdominal pain
Crohn's disease
Chronically sensitive bowels prone to diarrhea
irritable bowel syndrome
irritated stomach with vomiting; "stomach ache
gastritis
inflammation of the sac surrounding the heart
pericarditis
Inflammation of the sac surrounding the lungs causing pleuritic CP
pleurisy
Irritation of the ribs causing CP worsened by pressing on the sternum
costochondritis
Irritation of the chest wall causing pain with palpation of the chest
chest wall pain
fluid collecting around the lungs causing SOB or CP
pleural effusion
No Acute Distress.
NAD
yellowing of the sclera due to jaundice
Scleral icterus
yellowing of the skin
jaundice
What is the normal for this system: General?
Well developed, well nourished, no acute distress(NAD)
What is the normal for this system: eyes?
PERRL (pupils equal, round, reactive to light), EOMI (extraocular movements intact)
What is the normal for this system: ENT?
moist mucosa
What is the normal for this system: neck?
supple (able to bend). no lymphadenopathy
What is the normal for this system: cardiovascular?
well perfused. regular rate and rhythm. no murmurs, rubs, or gallops. distal pulses intact
What is the normal for this system: respiratory?
no respiratory distress. clear to auscultation bilaterally. no wheezes, rales, or rhonci
What is the normal for this system: gastrointestinal?
non-distended. soft. non-tender. no guarding, rebound, or rigidity
What is the normal for this system: extremites?
no edema. full ROM (range of motion)
What is the normal for this system: skin?
dry, no rashes. warm
What is the normal for this system: neurological?
alert and oriented. normal speech
What is the normal for this system: psychiatric?
normal affect
What does Complete Blood Count test look for?
infection and anemia
Complete Blood Count
CBC
infection is determined by..
high WBC count in CBC
Anemia is determined by ....
low Hgb or low Hct in CBC
white blood cells
WBC
hemoglobin
Hgb
Hematocrit
Hct
Complete blood count
CBC
basic metabolic panel
BMP
BMP looks for ...
electrolytes, kidney function, blood glucose level
high sodium
hypernatremia
low sodium
hyponatremia
high potassium
hyperkalemia
low potassium
hypokalemia
high glucose
hyperglycemia
low glucose
hypoglycemia
high bicarbonate
hypercarbia
low bicarbonate
Hypocarbia
high chloride
hyperchloremia
low chloride
hypochloremia
signs of dehydration in BMP
hypernatremia or hyponatremia
signs of poor kidney failure in BMP
hyperkalemia
signs that it may cause arrhythmia in BMP
hypokalemia
signs of renal insufficiency or failure in BMP
high blood urine nitrogen or high creatinine
signs of high blood sugar in BMP
hyperglycemia
signs of low blood sugar in BMP
hypoglycemia
signs of possible respiratory disease in BMP
hypercarbia
signs of hyperventilation (possible DKA) in BMP
hypocarbia
signs of possible dehydration
hyperchloremia or hypochloremia
Electrolytes studies in BMP are....
sodium, potassium, chloride
Kidney function in BMP is determined by
BUN and creatinine
comprehensive metabolic panel
CMP
CMP includes everything in BMP but also includes _____________ function test
liver
Liver function tests in CMP include..
AST, ALT, Alk Phos
Aspartate Transaminase
AST
Alanine Transaminase
ALT
Alkaline Phosphatase
alk phos
Signs of jaundice/liver failure in CMP
High total bilirubin (t. bili)
the examination of urine to determine the presence of abnormal elements
urinalysis
uralysis looks for signs of ____
UTI
UTI can be detected in uralysis by
high RBC count, high WBC count, and bacteria
Hematuria can be caused by
UTI, kidney stone, trauma, cancer, polycystic kidney disease, blood clotting disorders, and inflammation of the urinary system.
uses radiation, based on density, can detect bones
checks for fractures, pneumonia (lung infection), breast cancer (mammogram)
x-ray
computerized tomography
CT or CAT scan
a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body
CT scan
these are plain CT scans, where no contrast, or dye, is used. These are often used to visualize the brain, the lungs, the kidneys, and bones.
CT without (abbreviated to CT w/o)
Diagnoses that can be made using a CT w/o include:
Cerebrovascular accidents, lung infections like pneumonia, fractures, and kidney stones
With a CT angiogram, the patient is given contrast (or dye) through their IV. This means that the dye enters the bloodstream. The heart will pump the dyed blood throughout the body, so pretty much every blood vessel in the body will light up!
CT with IV Contrast aka CT Angiogram (abbreviated to CTA or CT w/)
CTAs are used to evaluate blood vessels and can diagnose things like:
aortic aneurysm, CVAs, problems with the carotid arteries, and pulmonary embolisms
O is the abbreviation for Per Os, or by mouth, so with this type of CT scan, the patient drinks the contrast dye. Then their entire GI system lights up!
CT Abdomen/Pelvis with PO Contrast (abbreviated to CT A/P w/ PO)
CT A/P w/ PO is used to look for GI conditions like:
appendicitis, bowel blockages, and diverticulitis
use high frequency sound waves to generate real-time images.
For any disease involving the reproductive organs ultrasounds are preferred because they do not use radiation.
Ultrasounds
Ultrasounds detect diseases such as
ovarian torsions, testicular torsions, ectopic pregnancies, DVT, gallbladder inflammation and gallbladder stones!
(electrocardiogram) instrument used in measuring the electrical potential during a heartbeat
EKG
Rhythm: Normal sinus rhythm; normal rhythm and rate 60-100
NSR
Rhythm: sinus bradycardia; normal rhythm and rate <60
SB
Rhythm: Sinus Tachycardia; normal rhythm and rate >100
ST
Rhythm: Atrial fibrillation
A fib
Rhythm: Atrial flutter
A flutter
Rhythm: Pacemaker is functioning
Paced
Rhythm: Supraventricular tachycardia
SVT
Ectopy: premature ventricular contraction
PVC
Ectopy: premature atrial contraction
PAC
Axis: left axis deviation
LAD
Axis: right axis deviation
RAD
Axis: Left Anterior Fascicular Block
LAFB
Interval: Left Bundle Branch Block
LBBB
Interval: Right Bundle Branch Block
RBBB
Interval: First Degree AV Block (2nd and 3rd degree exist)
1* AVB
QRS complex: left ventricular hypertrophy
LVH
QRS complex: poor R wave progression
PRWP
ST/T Segments: acute ST election
ST (up arrow)
ST/T Segments: acute ST depression
ST (down arrow)
ST/T Segments: Nonspecific ST/T changes
NSSST^'s
other ST/T Segments include....
reciprocal changes, no acute ST/T changes, T-wave inversions or T-wave flattening
Other intervals include
prolonged PR and prolonged QT
inferior leads
II, III, aVF
lateral leads
I, aVL, V5, V6
anterior leads
V3, V4
septal leads
V1, V2
History of present illness
HPI
Review of Systems
ROS
Medical Decision Making
MDM
What to write for consultation
Time, name of consultant, specialty service, recommendations
What to write for Re-evaluation
Timestamp, current status, status of CC, new complaints
What to write for Discharge
Guidelines for return, Follow up, Medicolegal
What to write for Procedure - Laceration Repair
Length, locations, anesthesia, local, description, contamination